Provider Demographics
NPI:1508109851
Name:CHANNICK, JAMES R (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:CHANNICK
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 RUSSELL RD
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301-1236
Mailing Address - Country:US
Mailing Address - Phone:610-644-6464
Mailing Address - Fax:610-981-6078
Practice Address - Street 1:2500 YORK RD
Practice Address - Street 2:SUITE 145
Practice Address - City:JAMISON
Practice Address - State:PA
Practice Address - Zip Code:18929-1068
Practice Address - Country:US
Practice Address - Phone:610-644-6464
Practice Address - Fax:610-981-6078
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW014679101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor